Thomas M. Piazza DDS - New Patient Form

WELCOME
Thank you for selecting our dental healthcare team. We will strive to provide you with the best dental care. To help us meet all you dental care needs, please fill out this form. If you have any questions or need assistance, please ask us.
PATIENT INFORMATION
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Home Phone *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Sex *
Email Address *
example@example.com
Cell Phone *

Area Code Phone Number
If Student, Name School/College *
City *
Patient's or Parents Employer *
Work Phone *

Area Code Phone Number
Spouse or Parent's Name *

First Name Last Name
Person to Contact in Case of Emergency *

First Name Last Name
Phone Number *

Area Code Phone Number
How did you hear about us? *

Insurance Referral Google
How long ago was your last dental visit? *
Name of Previous Dentist *
Phone Number *

Area Code Phone Number
DENTAL INSURANCE INFORMATION
Name of Insured *

First Name Last Name
Relationship to Patient *
Insured Date of Birth *

Month Day Year
Date
Name of Employer *
Insurance Company *
Policy Number *
Group Number *
Insurance Company Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Signature *

Clear
Date *

Month Day Year
Date

FINANCIAL AGREEMENT & GUIDELINES
APPOINTMENTS

Since we provide a 5-star service to our patients, the time scheduled is reserved just for you. Appointment reservations for visits broken without adequate notice (24 hours) or no call no show may incur a $65.00 charge.

INSURANCE ON ASSIGNMENT

As a courtesy, we will file your insurance and will do our best to maximize your benefits. We call to verify benefits & eligibility and go over your insurance with you at your initial appointment. To lower your initial "out of pocket expense", we ask that you take care of your estimated out-of-pocket portion of treatment at the time of service, including al deductibles. Balance is due upon completion of work. Any amount that insurance does not cover is patient responsibility. It is the patient's responsibility to provide our office with all necessary and accurate insurance information prior to appointments. If not given at the time of service, the patient becomes responsible for services rendered.

GUIDELINES
- Payment in full is due at the time of service for all emergency visits.
- If there is no dental insurance on file, payment in full is required at the time of service.
- For all services rendered to minor patients, we will hold the parent/guardian accompanying the minor on the first visit responsible for expenses incurred.
- We do not bill third parties.
- A finance charge of 1.5% monthly will apply to past due accounts after 60 days.
- You will be responsible for any charges associated with collection costs if your account goes to an outside collection agency due to an unpaid balance after 90 days.
- There will be a $35 fee added for returned checks.
FINANCING AVAILABLE on MAJOR WORK

We offer 6, 12, 18, or 21-month interest-free financing with approved credit through Care Credit.

CREDIT CARD

We accept Discover, MasterCard, Visa and American Express.
*

I have read and understand the financial policy outlined above and agree to be bound by its terms. I also understand and agree that such terms may be amended from time to time by this practice.
Signature *

Clear
Date *

Month Day Year
Date
Please verify that you are human *
Should be Empty:

WELCOME

PATIENT INFORMATION

DENTAL INSURANCE INFORMATION

PATIENT MEDICAL HISTORY

PATIENT DENTAL HISTORY

FINANCIAL AGREEMENT & GUIDELINES